Loosening the grip

When cautious, evidence informed writers such as Christiane Muth and Paul Glasziou describe a research paper as “pioneering work,” it is sensible to pay attention (doi:10.1136/bmj.h5145). The world’s health systems are besieged by ageing populations and multimorbidity. We struggle to find effective and affordable solutions. Research evidence, in its artificial bubble, may be limited by the age range of the study population and generally focuses on single therapies. The reality of medical care is different: older patients with complex chronic diseases, taking many drugs. Our evidence base and guidelines, the tools of best practice, tend not to cater for the messiness of clinical problems.

Applying several guidelines to patients with multimorbidity carries risks, explain Muth and Glasziou. Are the treatment effects equivalent to those seen in patients with a single disease? Might we precipitate potentially harmful interactions? Multiple guidelines mean multiple treatments, surely placing an undue burden on patients? To answer the question of effectiveness, Mary Tinetti and colleagues (doi:10.1136/bmj.h4984) studied three year survival in a group of older patients with multimorbidity taking nine cardiovascular drugs recommended by guidelines. Although there is some variation, the researchers conclude that average associations for survival are broadly similar to those reported in randomised controlled trials of patients with single diseases. Yet this finding does not mean that clinicians and patients must subject themselves blindly to the tyranny of guidelines. When it comes to avoiding harmful interactions and reducing the treatment burden on patients, Muth and Glasziou warn that a patient’s circumstances, preferences, and treatment goals must be considered.

The tyranny of regulation is just as much a problem. England’s Care Quality Commission is concerned about Addenbrooke’s Hospital in Cambridge, designating it as being under “special measures.” Keith McNeil, the hospital’s chief executive, resigned last month before the CQC’s inspection report was published (doi:10.1136/bmj.h5066). Is Addenbrooke’s, once celebrated as a flagship hospital, as big a failure as is being painted (doi:10.1136/bmj.h5278)? McNeil believes that a misunderstanding was at the core of the CQC inspection. He presented Addenbrooke’s as an academic specialist centre; staff described it as a district hospital with specialist services. The CQC seized on this disconnect between the values of board and staff, “a red flag to a bull,” and built a narrative of institutional failure. Addenbrooke’s faces many other challenges, including money and recruitment, but it may be an example of the over-regulation that some say blights the health service—its obsession with “grip.” McNeil rages against this control: “We would rather have a live patient than a well documented death.”

In today’s tyrannical healthcare, nothing is more certain than guidelines, regulation, and death. Kristian Pollock questions the orthodoxy that home is always the best and preferred place of death, a preoccupation that oversimplifies attitudes among patients and the public (doi:10.1136/bmj.h4855). Pollock offers the simple wisdom that “an unreflective focus on place as the determining factor of a good death distracts attention from the experience of dying.” In death, as in the implementation of guidelines and the scrutiny of regulation, the experience of patients is easily forgotten.